Benefits

Opt Out form - AFSCME Court employees
[Adobe Acrobat .pdf file]

Opt Out form - GAA Court employees
[Adobe Acrobat .pdf file]

Dependent Verification – IRS Form 4506T
[Adobe Acrobat .pdf file]

2009 Employee Reimbursement Account Enrollment form
[Adobe Acrobat .pdf file]

Enrollment/Change of Status Form
[Adobe Acrobat .pdf file]
- Instructions for the Enrollment/Change of Status Form
[Adobe Acrobat .pdf file]

Flexible Spending Reimbursement Claim Form for Medical/Dependent Care Expenses
[Adobe Acrobat .pdf file]

Flexible Spending Reimbursement Claim Form for Parking/Commuter Expenses
[Adobe Acrobat .pdf file]

Flexible Spending Account Plan Change in Status form
[Adobe Acrobat .pdf file]

2009 Open Enrollment Form
[Adobe Acrobat .pdf file]

Optical Reimbursement form
[Word .doc file]

Health and Welfare Plan
[Adobe Acrobat .pdf file]

LTD Plan
[Adobe Acrobat .pdf file]

Health Care Opt out Form (15%)
[Adobe Acrobat .pdf file]

Healthcare Opt Out Form - Elected Officials, Judges & Commission Employees
[Adobe Acrobat .pdf file]

2009 Open Enrollment Change Form - Retirees
[Adobe Acrobat .pdf file]

2010 FSA Enrollment form
[Adobe Acrobat .pdf file]

HIPAA Notice
[Adobe Acrobat .pdf file]

Women's Newborns & Mothers Health Notice
[Adobe Acrobat .pdf file]

Cobra Notice
[Adobe Acrobat .pdf file]

Medicare Drug Creditable Coverage Notice
[Adobe Acrobat .pdf file]

Forms...

• Training
• Tuition Reimbursement
• Job Application
• Leave of Absence
• Benefits
• Misc

Benefit Administration

Enrollment Page

Documents & Forms

View Benefit Guide

Wellness Program

Wayne County Building
600 Randolph
5th Floor
Detroit, MI 48226

Ph: (313) 224-5137
Fx: (313) 224-7419

Monday - Friday
8:00 a.m. - 4:30 p.m.